Hydrosonography in screening for intracavitary pathology in infertile women

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.

Transvaginal sonographic evaluation at different menstrual cycle phases in diagnosis of uterine lesions

Purpose:

Intrauterine lesions (IULs) are a common finding in women of reproductive age, particularly infertile women. Transvaginal sonography (TVS) is a popular tool for IUL detection, but there are conflicting data with respect to its accuracy.

Methods:

Five hundred and six women were enrolled into the study. Of these, 496 underwent hysterosalpingography and subsequent TVS six different times during the course of their menstrual cycle. If a lesion was detected, it was further evaluated by sonohysterography (SHG) and hysteroscopy.

Results:

Of 496 women, 41 were shown to have IULs by TVS and those lesions were confirmed in 39 by SHG and hysteroscopy. All 39 lesions were detectable during the ovulatory and early luteal phase (days 16–19) of the menstrual cycle. Accuracy of TVS during different phases was largely dependent on the size of the lesion. TVS falsely detected two lesions and missed fine adhesions in two patients.

Conclusion:

Accuracy of TVS in detection of IULs is highly dependent on the menstrual cycle phase, with the ovulatory and early luteal phase being the optimal time for this examination.

[Anatomic evaluation of the female of the infertile couple]

One third of infertility cases are due to anatomical abnormalities of the female reproductive tract: endometrial polyps (33%), bilateral tubal blockage (12%), hydrosalpinx (7%), sub-mucosal fibroids (3%) and pelvic endometriosis. These may need surgical correction which could restore fertility. This review aim to determine which examinations should be performed first. Hysterosalpingography shows sensitivity of only 65% but it increases the achievement of spontaneous pregnancy by three times. Office hysteroscopy has an excellent sensitivity (>95%) for diagnosing intra-uterine lesions. Pelvic ultrasound, whose good sensitivity is improved by adding 3D imaging and hysterosonography, seems as efficient as office hysteroscopy in diagnosing uterine cavity abnormalities. Moreover, it also efficiently diagnoses pelvic diseases such as hydrosalpinx or endometrioma without laparoscopy. A first line laparoscopy is indicated in for woman suspected of endometriosis or tubal pathology (history of complicated appendicitis, previous pelvic surgery, pelvic inflammatory disease). For the others straight forward cases, the majority of patients, hysterosalpingography and pelvic ultrasound seem to be sufficient as primary diagnostic tool.

Comparison of the pain experienced by infertile women undergoing hysterosalpingo contrast sonography or radiographic hysterosalpingography

OBJECTIVE

To evaluate the pain and cause of pain experienced by women undergoing hysterosalpingography (HSG) and contrast hysterosalpingo sonography (HyCoSy) with air in a saline solution for the assessment of uterine and tubal patency.

METHOD

In this prospective study, 121 infertile women undergoing these 2 procedures measured the pain incurred using a digital/analog scale (1-10). We looked for correlations between pain level and variables pertaining to the procedures. Vagal effects and their persistence were also recorded.

RESULTS

The pain was less during HSG (median, 5) than during HyCoSy (median, 7). It was greater than menstrual pain for 38.8% of participants during HSG and for 70.5% of participants during HyCoSy. There was no correlation between pain and difficult catheter passage, degree of tubal obstruction, volume of contrast medium injected, or presence of IgG antibodies to Chlamydia when these variables were studied for HyCoSy alone. However, the strong correlation between pain score and volume of contrast medium injected during each procedure seems to explain the significantly higher pain levels during HyCoSy (P<0.001). In 65.3% and 57.8% of participants, respectively, the pain disappeared immediately after the HSG or HyCoSy. Only mild vagal effects were recorded following both procedures, in 0.8% of participants after HSG and 2.5% of participants after HyCoSy.

CONCLUSION

Hysterosalpingo contrast sonography is similar to HSG regarding rapidity of pain disappearance, and infrequency and moderation of vagal effects, but the level of pain is slightly higher, probably due to the greater volume of medium injected.

Congenital malformations of the female genital tract: the need for a new classification system

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.